Statin use in low-income and middle-income countries – Authors' reply
Authors: David Flood, Maja E Marcus, Silver K Bahendeka, Sahar Saeedi Moghaddam, Corine Houehanou, Sebastian Vollmer, Mark D Huffman
Journal: The Lancet Global Health (2022)

Authors' reply We thank Florian Neuhann and colleagues for their interest in our study on statin use in low-income and middle-income countries. We agree with many of their points. Large datasets can aid in understanding treatment gaps. Local data should inform the intervention priorities of policy makers—not just for statins but for all health system investments. Scaling up treatment of hypertension and diagnosis of diabetes are also global cardiovascular health priorities. We wish to make a few additional comments. First, although our study did not include data from Malawi as no response rate was reported in the country's 2017 Stepwise Approach to Surveillance (STEPS) survey, the estimates presented by the authors suggest that a sizeable proportion of the population in the country would also benefit from statin therapy. The 2017 Malawi STEPS report states that 9·1% of individuals aged 40–69 years had a 10-year cardiovascular disease risk of 30% or more, or had existing cardiovascular disease. We took the opportunity to analyse microdata from this survey using the methods described in our paper and found that statins were used by fewer than 10% of these individuals at high risk. Second, a crucial clinical detail that might be overlooked by the authors is that the relative risk reduction on cardiovascular disease outcomes (including cardiovascular disease events and all-cause mortality) for antihypertensive and statin therapies is roughly commensurate,1Karmali KN Lloyd-Jones DM Berendsen MA et al.Drugs for primary prevention of atherosclerotic cardiovascular disease: an overview of systematic reviews.JAMA Cardiol. 2016; 1: 341-349Crossref PubMed Scopus (46) Google Scholar and the absolute benefit for both is primarily dependent upon a given patient's baseline cardiovascular disease risk.2Rahimi K Bidel Z Nazarzadeh M et al.Pharmacological blood pressure lowering for primary and secondary prevention of cardiovascular disease across different levels of blood pressure: an individual participant-level data meta-analysis.Lancet. 2021; 397: 1625-1636Summary Full Text Full Text PDF PubMed Scopus (100) Google Scholar, 3Baigent C Keech A Kearney PM et al.Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins.Lancet. 2005; 366: 1267-1278Summary Full Text Full Text PDF PubMed Scopus (5635) Google Scholar Thus, the individuals most likely to benefit from antihypertensive medications are generally the same individuals who would also benefit from statins. As a result, we would not favour separating antihypertensive and statin treatment priorities, as suggested by Neuhann and colleagues. Third, although we agree that use of non-laboratory risk tools holds promise in guiding statin eligibility, we also believe that access to affordable lipid measurements will continue to be an important goal in resource-scarce health systems. The WHO non-laboratory risk equations perform poorly among individuals with diabetes.4Kaptoge S Pennells L De Bacquer D et al.World Health Organization cardiovascular disease risk charts: revised models to estimate risk in 21 global regions.Lancet Glob Health. 2019; 7: e1332-e1345Summary Full Text Full Text PDF PubMed Scopus (294) Google Scholar Therefore, risk-stratification among these patients ideally should use laboratory-based risk equations that require total cholesterol; however, we also note that guidelines typically recommend at least moderate-dose statin treatment in all adults with diabetes. In our experience, there is also often substantial resistance and scepticism among physicians and patients to initiating statin therapy without baseline lipid measurements. Finally, the authors argue that a large improvement in the cardiovascular disease burden can be attained through scaling up antihypertensive treatment and diabetes screening rather than statins. We previously published in The Lancet Global Health a modelling study showing that, among people with diabetes, improving access to antihypertensive and statin treatment would reduce more diabetes complications than focusing on screening to increase diabetes diagnoses.5Basu S Flood D Geldsetzer P et al.Estimated effect of increased diagnosis, treatment, and control of diabetes and its associated cardiovascular risk factors among low-income and middle-income countries: a microsimulation model.Lancet Glob Health. 2021; 9: e1539-e1552Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar But, ultimately, we believe that diagnosis and treatment (including with statins) are both cornerstones of an integrated, population-level approach to the management of diabetes and cardiovascular risk factors in primary care. In conclusion, statins are one of the most important tools in the prevention of cardiovascular disease in the clinical armamentarium. We urge funders and policy makers to work together to provide access to this safe, effective, and cost-effective class of medicines for all patients for whom they are appropriate. MDH has patents pending for heart failure polypills. MDH has received meeting or travel support from the American Heart Association and World Heart Federation. MDH has an appointment at The George Institute for Global Health, which has a patent and licence, and has received investment funding with the intent to commercialise fixed-dose combination therapy through its social enterprise business called George Medicines. DF reports grant funding within the past 3 years from a Pilot and Feasibility Grant funded by the Michigan Center for Diabetes Translational Research (NIH Grant P30-DK092926) and a grant from the Swinmurn Foundation to implement a sustainable diabetes clinic in Guatemala. DF also reports volunteer affiliations with Wuqu’ Kawoq and GlucoSalud, outside of the submitted work. During the course of the study, DF received research fellowship funding from National Clinician Scholars Program at the University of Michigan Institute for Healthcare Policy and Innovation. All other authors declare no competing interests. Use of statins for the prevention of cardiovascular disease in 41 low-income and middle-income countries: a cross-sectional study of nationally representative, individual-level dataIn a diverse sample of LMICs, statins are used by about one in ten eligible people for the primary prevention of cardiovascular diseases and one in five eligible people for secondary prevention. There is an urgent need to scale up statin use in LMICs to achieve WHO targets. Policies and programmes that facilitate implementation of statins into primary health systems in these settings should be investigated for the future. Full-Text PDF Open AccessStatin use in low-income and middle-income countriesIn their Article, Maja Marcus and colleagues (March, 2022)1 report on primary prevention of cardiovascular disease for individuals aged 40–69 years with respect to WHO-recommended indications for drug treatment with statins. They found that approximately 10% of the individuals from health surveys of different low-income and middle-income countries were eligible for statins, but only 10% (1% of all individuals surveyed) of those eligible actually received a statin.1 In view of this low coverage, they call for the implementation of statin therapy into primary health care. Full-Text PDF Open Access